The Turkish version of the problem areas in diabetes-parents of teens (P-PAID-T): Cross-cultural adaptation, reliability, and validity

OBJECTIVE

To examine the Turkish validity and reliability of the Problem Areas in Diabetes- Parents of Teens (P-PAID-T) scale and its psychometric properties for determining the parents' diabetes-related distress.

METHODS

The study included the parents of 200 adolescents with T1DM for at least a year. P-PAID-T and a demographic data form were used for data collection. Davis technique was used for the content validity of the scale. The scale's reliability was tested using test-retest, and its internal reliability was analyzed with Cronbach's alpha test. Exploratory Factor Analysis (EFA) was used to analyze the factor structure. Confirmatory Factor Analysis (CFA) was used to evaluate the fit of the scale.

RESULTS

69.5% (n = 139) of the participants were mothers. Compared to the fathers, the mothers' mean P-PAID-T score was significantly higher. Parents of sons, who used insulin injections for their children, and had a college degree or higher education level had higher P-PAID-T scores. The test-retest correlation coefficient of the scale was 0.977. The Cronbach α value of the scale was 0.901. The results of confirmatory factor analysis were x2/df = 2.931, GFI = 0.736, CFI = 0.711, NFI = 0.628, NNFI = 0.660, RMSEA = 0.141.

CONCLUSION

The Turkish version of P-PAID-T was a valid and reliable screening tool for measuring diabetes stress in parents of adolescents with T1DM.

PRACTICE IMPLICATIONS

Nurses could use the Turkish version of P-PAID-T to monitor parental diabetes distress and organize interventions; also Turkish P-PAID-T could facilitate research on diabetes distress for parents of adolescents with T1DM.

Catch-up Growth and Discontinuation of Fludrocortisone Treatment in Aldosterone Synthase Deficiency

BACKGROUND

Aldosterone synthase deficiency (ASD) caused by mutations in the CYP11B2 gene is characterized by isolated mineralocorticoid deficiency. Data are scarce regarding clinical and biochemical outcomes of the disease in the follow-up.

OBJECTIVE

Assessment of the growth and steroid profiles of patients with ASD at the time of diagnosis and after discontinuation of treatment.

DESIGN AND METHOD

Children with clinical diagnosis of ASD were included in a multicenter study. Growth and treatment characteristics were recorded. Plasma adrenal steroids were measured using liquid chromatography-mass spectrometry. Genetic diagnosis was confirmed by CYP11B2 gene sequencing and in silico analyses.

RESULTS

Sixteen patients from 12 families were included (8 females; median age at presentation: 3.1 months, range: 0.4 to 8.1). The most common symptom was poor weight gain (56.3%). Median age of onset of fludrocortisone treatment was 3.6 months (range: 0.9 to 8.3). Catch-up growth was achieved at median 2 months (range: 0.5 to 14.5) after treatment. Fludrocortisone could be stopped in 5 patients at a median age of 6.0 years (range: 2.2 to 7.6). Plasma steroid profiles revealed reduced aldosterone synthase activity both at diagnosis and after discontinuation of treatment compared to age-matched controls. We identified 6 novel (p.Y195H, c.1200 + 1G > A, p.F130L, p.E198del, c.1122-18G > A, p.I339_E343del) and 4 previously described CYP11B2 variants. The most common variant (40%) was p.T185I.

CONCLUSIONS

Fludrocortisone treatment is associated with a rapid catch-up growth and control of electrolyte imbalances in ASD. Decreased mineralocorticoid requirement over time can be explained by the development of physiological adaptation mechanisms rather than improved aldosterone synthase activity. As complete biochemical remission cannot be achieved, a long-term surveillance of these patients is required.

Characteristics of Turkish children with Type 2 diabetes at onset: a multicentre, cross-sectional study

AIMS

To describe the baseline clinical and laboratory findings and treatment modalities of 367 children and adolescents diagnosed with Type 2 diabetes in various paediatric endocrinology centres in Turkey.

METHODS

A standard questionnaire regarding clinical and laboratory characteristics at onset was uploaded to an online national database system. Data for 367 children (aged 6-18 years) newly diagnosed with Type 2 diabetes at 37 different paediatric endocrinology centres were analysed.

RESULTS

After exclusion of the children with a BMI Z-score < 1 SD, those with genetic syndromes associated with Type 2 diabetes, and those whose C-peptide and/or insulin levels were not available, 227 cases were included in the study. Mean age was 13.8 ± 2.2 (range 6.5-17.8) years, with female preponderance (68%). Family history of Type 2 diabetes was positive in 86% of the children. The mean BMI was 31.3 ± 6.5 kg/m² (range 18.7-61) and BMI Z-score was 2.4 ± 0.8 (range 1-5). More than half (57%) of the children were identified by an opportunistic diabetes screening due to existing risk markers without typical symptoms of diabetes. Only 13% (n = 29) were treated solely by lifestyle modification, while 40.5% (n = 92) were treated with metformin, 13% (n = 30) were treated with insulin, and 33.5% (n = 76) were treated with a combination of insulin and metformin initially. Mean HbA_1C levels of the insulin and combination of insulin and metformin groups were 98 (11.1%) and 102 mmol/mol (11.5%), respectively, and also were significantly higher than the lifestyle modification only and metformin groups mean HbA_1C levels (70(8.6%) and 67 mmol/mol (8.3%), respectively).

CONCLUSIONS

An opportunistic screening of children who are at high risk of Type 2 diabetes is essential, as our data showed that > 50% of the children were asymptomatic at diagnosis. The other important result of our study was the high rate of exclusion from the initial registration (38%), suggesting that accurate diagnosis of Type 2 diabetes in youth is still problematic, even for paediatric endocrinologists.

The Etiology and Clinical Features of Non-CAH Gonadotropin-Independent Precocious Puberty: A Multicenter Study

AIM

The causes of gonadotropin-independent precocious puberty are diverse, and often have overlapping clinical and biochemical features. With the exception of congenital adrenal hyperplasia (CAH), disorders that cause gonadotropin-independent precocious puberty (GIPP) are uncommon. The literature is devoid of any large-scale studies on the etiologic distribution of GIPP. The aim of this study was to determine the frequency of each etiology in a cohort of patients with GIPP (excluding those with CAH), and to evaluate the clinical and laboratory features of these patients.

MATERIALS AND METHODS

This multicenter, nationwide web-based study collected data on patients who presented with non-CAH GIPP in Turkey.

RESULTS

Data were collected for 129 patients (102 girls and 27 boys) from 29 centers. Based on the data collected, the estimated prevalence of non-CAH GIPP in the studied population was 14 in 1 000 000 children. Functional ovarian cyst was the most common etiology, accounting for 37% of all cases, followed by McCune-Albright syndrome (MAS) (26%). Among the patients with MAS, 11.7% had fibrous dysplasia, 32.3% had café-au-lait spots, and 52.9% had both. Human chorionic gonadotrophin-secreting tumors included choriocarcinoma of the liver, hepatoblastoma, and germ cell tumors of the sellar-suprasellar region and mediastinum. Patients with adrenocortical tumors presented at an earlier age than those with other etiologies. Ovarian tumors included mature cystic teratoma, dysgerminoma, juvenile granulosa tumor, and steroid cell tumor. Despite overlapping features, it was possible to identify some unique clinical and laboratory features associated with each etiology.

CONCLUSION

This largest cohort of patients with non-CAH GIPP to date yielded an estimation of the frequency of non-CAH GIPP in the general pediatric population and showed that girls were affected at a rate 4-fold greater than that of boys owing to functional ovarian cysts and MAS, which were the two most common etiologies. The data collected also provided some unique characteristics associated with each etiology.

Rare Causes of Primary Adrenal Insufficiency: Genetic and Clinical Characterization of a Large Nationwide Cohort

CONTEXT

Primary adrenal insufficiency (PAI) is a life-threatening condition that is often due to monogenic causes in children. Although congenital adrenal hyperplasia occurs commonly, several other important molecular causes have been reported, often with overlapping clinical and biochemical features. The relative prevalence of these conditions is not known, but making a specific diagnosis can have important implications for management.

OBJECTIVE

The objective of the study was to investigate the clinical and molecular genetic characteristics of a nationwide cohort of children with PAI of unknown etiology.

DESIGN

A structured questionnaire was used to evaluate clinical, biochemical, and imaging data. Genetic analysis was performed using Haloplex capture and next-generation sequencing. Patients with congenital adrenal hyperplasia, adrenoleukodystrophy, autoimmune adrenal insufficiency, or obvious syndromic PAI were excluded.

SETTING

The study was conducted in 19 tertiary pediatric endocrinology clinics.

PATIENTS

Ninety-five children (48 females, aged 0-18 y, eight familial) with PAI of unknown etiology participated in the study.

RESULTS

A genetic diagnosis was obtained in 77 patients (81%). The range of etiologies was as follows: MC2R (n = 25), NR0B1 (n = 12), STAR (n = 11), CYP11A1 (n = 9), MRAP (n = 9), NNT (n = 7), ABCD1 (n = 2), NR5A1 (n = 1), and AAAS (n = 1). Recurrent mutations occurred in several genes, such as c.560delT in MC2R, p.R451W in CYP11A1, and c.IVS3ds+1delG in MRAP. Several important clinical and molecular insights emerged.

CONCLUSION

This is the largest nationwide study of the molecular genetics of childhood PAI undertaken. Achieving a molecular diagnosis in more than 80% of children has important translational impact for counseling families, presymptomatic diagnosis, personalized treatment (eg, mineralocorticoid replacement), predicting comorbidities (eg, neurological, puberty/fertility), and targeting clinical genetic testing in the future.

Does amnioreduction increase success of emergency cervical cerclage in cases with advanced cervical dilatation and protruding membranes?

OBJECTIVE

To investigate whether amnioreduction has any impact on emergency cervical cerclage outcome.

MATERIALS AND METHODS

Data of women who underwent emergency cervical cerclage for advanced cervical dilatation and protruding membranes were analyzed retrospectively.

RESULTS

During the study interval, a total of 56 women who were underwent amnioreduction (n=26) and who did not (n=30) were eligible for analysis of the study. Gestational age at cerclage, delivery, and prolongation of pregnancy interval were comparable between the groups (21.3 ±3.3 vs. 20.6 ±3.1 weeks; p = 0.44; 28.3 ±6.1 vs. 28.1 ±5.6 weeks; p = 0.74; 53.7± 46.1 vs. 47.3± 36.7 days; p = 0.56 respectively). Number of live birth rates and perinatal mortality rates were also not statistically significantly different between the groups (73.1% vs. 70.0%; p = 0.80; 15.4% vs. 13.3%; p = 0.83).

CONCLUSIONS

Emergency cerclage yields live take home baby rates in more than half of the patients. The decision to perform amnioreduction should be based on suspicion of chorioamnionitis and patient's motivation to know exactly what is the risk of chorioamnionitis.

Does removal of CU-IUD in patients with biofilm forming candida really maintain regression of clinical symptoms?

OBJECTIVE

To evaluate whether symptoms and recurrence would differ with and without Cu-IUD removal in patients with concomitant biofilm forming Candida spp.

METHODS

The data of 270 consecutive patients wearing TCu380A Cu-IUD were evaluated. Among these patients, 100/270 were found to have Candida spp. isolated from the tail of Cu-IUD or vaginal samples. These patients were investigated in four groups: Group 1 (n = 24; Biofilm (+), Cu-IUD removed), Group 2 (n = 14; Biofilm (+), Cu-IUD not removed), Group 3 (n = 29; Biofilm (-), Cu-IUD removed), Group 4 (n = 33; Biofilm (-), Cu-IUD not removed). Patients in each group were followed for clinical signs and symptoms for 8-16 months and compared to each other.

RESULTS

Symptoms, physical findings and candida positivity have decreased statistically significantly in Group 1 one year after removal of Cu-IUD (95.8% vs. 4.2%, p < 0.01; 95.8% vs. 4.2%, p < 0.01; 100% vs. 8.3%, p < 0.01 respectively). In Group 2, symptoms, physical findings and candida positivity have decreased after follow-up, but without a statistical significance. In Group 3, all the parameters have decreased, but only decrease in candida positivity has reached statistical significance (100% vs. 48.3%, p < 0.01). In Group 4 - as in Group 1- symptoms, physical findings and candida positivity have decreased statistically significantly (48.5% vs. 18.2%, p = 0.01; 72.7% vs. 48.5%, p = 0.05; 100% vs. 51.5%, p < 0.01 respectively).

CONCLUSION

Biofilm forming microorganisms should be considered in the management of vaginal infections or symptoms for safer use of intrauterine devices.

Integrating cervical length measurement into routine antenatal screening and only emergency cerclage when indicated

PURPOSE

To integrate cervical length measurement into antenatal screening and apply emergency cerclage when indicated to prevent spontaneous deliveries at < 34 weeks of gestation.

METHODS

Cervical length measurements of 400 pregnant volunteers were obtained at gestational weeks 12-14, 18-20 and 28-32. Whenever a cervical measurement < 30 mm was observed, vaginal cultures and bacterial vaginosis were investigated, and weekly cervical length measurements were performed thereafter. Emergency cerclage was performed whenever complete cervical effacement and > or = 3 cm cervical dilatation were observed before 32 completed weeks of gestation. We adopted and tested a strategy of only emergency cerclage application when clinically indicated after ultrasound screening and microbial monitoring of short cervices. Patients were given cyclooxygenase-inhibitors, progesterone, and antibiotics in the postoperative period.

RESULTS

Spontaneous preterm births at < 34 weeks of gestation occurred in 15 women (3.8%). We performed five emergency cerclages according to the presented screening strategy between 20-28 weeks of gestation all of which reached > 34 weeks. We successfully postponed 62.5% (5/8) of deliveries before 32 completed weeks and 33.3% (5/15) of deliveries before 34 completed weeks.

CONCLUSION

Routine cervical length measurement combined with serial transvaginal sonograms and vaginal microbial monitoring of the short cervices will avoid unnecessary prophylactic cerclages while increasing the success of emergency cerclages performed upon solid clinical findings.

GABAergic modulation of yawning behavior

The hypothetical modulation by GABAergic neurons of yawning behavior in the rat was explored with GABA-active drugs. Gamma-acetylenic-GABA, a specific inhibitor of GABA-T, increases yawning frequency when injected at a dose of 7 mg/kg. Baclofen, a GABAB agonist (3 mg/kg), inhibits yawning completely; GABA antagonists, bicuculline and picrotoxin, at subconvulsant doses, also decrease yawning. All drugs were injected intraperitoneally with the exception of apomorphine, which was injected subcutaneously. It is suggested that GABAB receptors play a role in yawning behavior by modulating ACh release, and that GABAA receptors may modify yawning frequency by modulating inhibitory influences on ACh neurons.